The following benefit highlight information is for enrollment effective January 1, 2021. You’ll find many $0 benefits, as well as prescription gap coverage, health and wellness programs – and much more.
|2021 Benefits||Connected Care Select (HMO C-SNP)|
|Monthly Plan Premium*||$0 copay|
|Deductible (Medical)||$0 copay|
|Maximum Out-of-Pocket (MOOP)||$1499|
|Inpatient Hospitalization||$0 copay unlimited days|
Outpatient Surgery (Hospital)
Ambulatory Surgical Center
|Primary Care Office Visit||$0 copay|
|Specialty Office Visit||$0 copay|
|Preventive Services||$0 copay|
|Emergency Room||$90 copay, waived if admitted within 24 hours|
|Urgent Care||$0 copay|
|Worldwide Emergency Coverage||$90 copay ($25,000 Maximum Benefit Coverage Amount)|
|Diagnostic Radiology Services (CT, MRI, PET)||$0 copay|
|Durable Medical Equipment/DME (wheelchairs, oxygen, etc.)||0% Under $500 , 20% $500 or more|
|Routine Hearing Exam||$0 copay (1 exam per year)|
|Hearing Aid Allowance||$400 every 2 years Reimbursable Allowance|
|Preventive Dental Coverage||$0 copay|
|Routine Eye Exam||$0 copay (1 exam per year)|
|Contacts and Eyeglasses Allowance||$150 limit every 2 years Reimbursable Allowance|
|Skilled Nursing Facility||
$0 per day (Days 1 - 20)
$50 per day (Days 21 - 51)
$0 per day (Days 52 -100)
|Ambulance||$200 waived if admitted|
|Tier 1: Preferred Generic||$0 Standard Retail (31-day Supply)|
|Tier 2: Generic||$10 Standard Retail (31-day Supply)|
Tier 3: Preferred Brand
||$45 Standard Retail (31-day Supply)|
Tier 4: Non-Preferred Brand
||$95 Standard Retail (31-day Supply)|
Tier 5: Specialty Tier
Tier 6: Select Care Drugs
||$0 Standard Retail (31-day Supply)|
*You must continue to pay your Medicare Part B premium
*People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.
For more information about Low Income Subsidy with Golden State Medicare Health Plan, click here
Individuals must have both Part A and Part B to enroll in the plan.
You must use plan providers except in emergent or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor Golden State Medicare Health Plan will be responsible for the costs.
In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances, and quanitity limitations and restriction may apply.
Members must receive all routine care from plan providers.
This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments, and restrictions may apply. Benefits, premiums, co-payments and co-insurance may change on January 1 of each year.
Last Update : 10/01/2020